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Asthma: Symptoms, Morbidity and Mortality

Asthma symptoms include one or more of the following:

Cough, sensation of tight chest, shortness of breath and phlegm. Strongly suggestive of asthma or pre-asthma are cough elicited by exercise or any combination of the above symptoms elicited by exercise. Resolution of these symptoms by inhalation of “asthma pumps” strongly suggests that the patient is asthmatic even if patient does not think so or even if the doctor did not tell patient of that possibility.  (“Asthma pumps” include a multitude of different brand names that can be grouped into bronchodilators, inhaled cotrtico-steroids, or a combination of inhaled corticosteroids with a medium or long acting bronchodilator).

According to the National Surveillance of Asthma: United States, 2001–2010 the incidence of asthma has been steadily rising from 2001 to 2010 and the asthma-mortality in 2009 was 3,388 people.46 Of note is that when the risk factors or predictors of death were analyzed several parameters were found to be related to the possibility of death during an asthma attack (like recent admission to the hospital, intubation etc.), but asthma severity was not one of those factors. This means that asthma severity does not appear to be a predictor for mortality. In other words asthma-related deaths do not occur only in the cases of severe asthma (as common sense would suggest) but also in mild asthmatics. A “common sense” explanation to this suggestion could be that a severe asthma attack could be triggered by sudden exposure to a large amount of allergens or other environmental irritants or sudden exposure to allergens or irritants to which the patient is extremely sensitive or a combination of those, so that a patient that in a particular moment faces the above circumstances, could develop a severe reaction with a severe asthma attack even if the patient had up to that moment only a mild case of asthma.

Asthmatic patients are more difficult to manage with immunotherapy. The air way in asthmatic patients is “more irritable”, in other words, the asthmatic patient can easily go into bronchospasm (“closure” of the lower airways) due to exposure to allergens or other irritants. If this “closure” of the lower airways upon exposure to an allergen or irritant elicits an overt asthma attack, it does not take a long stretch of the imagination to understand that an asthmatic patient can die while in bronchospasm.

Because injection immunotherapy can be complicated with a severe reaction involving the lungs (therefore with risk of bronchospasm), and because this type of severe reaction is clearly more likely in the asthmatic patient, 47,48,49 many allergy practitioners are reluctant to treat asthmatic patients with allergy shots. This is understandable as it is not difficult to conceive that a severe asthma attack can lead into death. If it is more likely to have a severe reaction in the asthmatic patient common sense would dictate do not treat that patient.

This is what I call the “paradox in the management of the asthmatic patient”:

  1. While the asthmatic patient is the one that is at risk of death due to the allergic disease, the asthmatic patient often times is not offered immunotherapy even though Immunotherapy is a treatment that can modify the immunological system 50 so that the allergic condition resolves leading into a significant improvement or even cure of the asthmatic condition.
  2. Even though it is clearly established in the world’s literature that a child with allergies has a 1 in 5 chance of becoming asthmatic, the present immunotherapy guidelines do not advise to offer immunotherapy to children younger than 5 years of age.

We strongly believe that in the above two circumstances immunotherapy should be considered for the appropriate management of the patient. If injectable immunotherapy involves risks SLIT should then be considered as the main treatment modality.

In our opinion SLIT is indeed uniquely positioned to be considered as the treatment of choice for the treatment of the asthmatic or the very young patient.

It is important to repeat the concepts above discussed:

While asthma is a serious disease that can even lead to the death of the affected patient, immunotherapy is a treatment than can lead into symptomatic improvement and even to the cure of the disease.

SLIT is ideal approach to treat the asthmatic patient because it is much safer than injection immunotherapy. We strongly believe that the asthmatic patient (adult or child) is an ideal candidate for treatment with sublingual immunotherapy.

DO I HAVE ASTHMA? NOT ME, I DO NOT HAVE ASTHMA

Lastly it is also important to discuss  “borderline cases”:

It is common to find young children with chronic cough. Recurrent or persistent cough is often one of the ways asthma can present itself. When cough is the only symptom of the asthmatic patient, it is called “Cough variant asthma”.

In clinical practice it is also very common to find patients with asthma symptoms who deny being asthmatic. Sometimes these patients are being successfully treated with “asthma pumps” but still they do not realize they have asthma. Some of these patients have only seasonal symptoms (for example the patients that have asthma “only” in the spring time). These are asthmatic patients. They react to environmental allergens. If left to its own evolution, the disease is likely to progress, so that the patient will ultimately react to other allergens and the asthma or other allergic symptoms can become more and more prevalent as years go by. Eventually the patient will be affected not only in a particular season but throughout more seasons and eventually all year long. As time goes by it is likely that the patient will develop more symptoms and that the pre-existent symptoms will become more severe.

In our office we studied a non-selected sample of 60 patients and we were surprised to find that no less than 70% had one or more asthma symptoms and/or used asthma medications but that only 21% considered themselves as being asthmatic. Another interesting finding was that of the 54 patients that either had asthma or asthma symptoms, 53 had cough as one of the symptoms. These results were published in a paper whose main objective was to evaluate the change in the value of the peak flow (a simple and quick way to have a rough overall idea of pulmonary function).51 For more on assessment of lung function (Pulmonary function studies) click here. This is a very interesting paper because while it demonstrated that immunotherapy elicited an improvement in the peak flow value in all patients (asthmatic or not) it made clear that many patients have asthma symptoms while being unaware of that fact. This has important safety implications for the allergy practitioner. The patient that is more likely to have a severe reaction to an allergy shot is the one that has inflammation in the lower airway, in other words the known or unknown asthmatic patient.

Bibliography

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